Among the items cleared from the bookshelf was a well-worn copy of A Report on the American Nurses' Association Studies of Nursing Functions,1 copyright 1958 and sub-titled Twenty Thousand Nurses Tell Their Story. The 1950 House of Delegates of the American Nurses Association (ANA) approved a five-year program of research to delineate and analyze nursing functions. Forty-eight separate studies funded by the ANA, the American Nurses Foundation, and private sources are synthesized in the text. The introductory chapter states that between 1951 and 1957 approximately 175,000 nurses paid voluntarily, out of their pockets, for the research reported in the book. Until recently, the American Journal of Nursing (AJN) was ANA's official journal and the organization's business was routinely and vigorously reported in the journal. Fortunately for the curious, many libraries have digitized the very old copies of AJN. The library obliged my curiosity with several 1950s articles about the program. One article identified the three purposes of the research program. First purpose, to determine what should be the functions and relationships of institutional nursing personnel - professional, practical, and auxiliary - to improve nursing care and use nursing personnel most effectively and economically. Second purpose, to determine the proportion of nursing time that should be provided by each group and in what situations. Third purpose, to use the findings of the first two purposes nationally in all types of hospitals to benefit nurses, the entire profession, and the people they serve.2 Individual studies were conducted by state nurses' associations, local groups, and universities and included nurses, psychologists, and sociologists as individual and team member researchers.1 And the cost? It was estimated that the cost of the program would be equal to $1.00 per member per year for a period of five years.2
Nurses' demographic findings included a lot of data points we would not collect today. Questions about "social origins" assumed that the workforce was all female. For example, the reports contain information about the occupational status of nurses' fathers (higher, middle, lower) and husbands (higher, middle, lower); number of children in the family of origin; questions about having grown up on a farm; marital status, number of children; religious affiliation; and memberships in clubs or organizations. In discussing the racial and ethnic makeup of the nursing workforce of the 1950s, being nearly all White and female, it was suggested that nursing must not appeal to ethnic and minority groups, yet it was recognized that professional nursing did little to "tap the reservoir" of minority groups. Nursing was seen as a steppingstone into the middle class for girls at a time when career options were limited. In discussing salary, one report offered the tongue in cheek advice: if you are interested in increasing your earnings, stay single and get older!1
Regarding nursing functions, what data was collected? The individual studies were designed to answer one or more of the eight core questions developed by the ANA Master Plan.
1. Actual duties of nursing personnel - What do they do?
2. Interpretation of duties of nursing personnel - What do they think they do? What do others think they do?
3. Ideal duties of nursing personnel - What do they think they should do? What do others think they should do?
4. Satisfactions and dissatisfactions.
5. Interpersonal and functional relationships of nursing personnel with other nursing personnel such as head nurse to supervisor, general duty nurse to practical nurse, and so on.
6. Attitudes of nurses to patients, physicians, co-workers, and the public, and attitudes of these groups to nurses.
7. Relationship of education to performance of duties.
8. Career dynamics and the nurse as a person.3
And what were the findings? Detailed answers to these questions are included in the aforementioned book. However, thanks to AJN, a short synopsis of the functions of the general duty nurse were summarized in a publication along with the standards for general duty nursing, standards for hospital-based nursing service, professional standards for nurse conduct, standards related to the community, and qualifications for practice as a general duty nurse.4 See Table 1 for functions of the general duty nurse.
The book is punctuated with stories and quotes by nurses like this one describing her work in the maternity word:
The important thing is to be with the patient as much as you possibly can... I think more than anything, most women need human contact - not to be left alone. The patient wants comfort from the nurse - the knowledge that you are there, and everything is secure.1, pg 152
A reported 15% of nurses left nursing after marriage and 75% of nurses left nursing after having children. As for choosing private duty assignments, one older nurse with children stated:
[My] youngest child [is] now in college, but I am physically unable to work regularly - thus private duty - nonetheless, I love nursing and cannot give it up entirely.1, pg 266
Other interesting facts are recorded, such as 77% of nurses surveyed (n = 2435) agreed that nurses should rise in hospital situations when a doctor enters the room. Some things change for the better.
Reviewing this research is reflective of how far we have traveled in our collective professional journey. As a doctoral student, my program annually hosted Dr. Hildegard Peplau as a visiting professor. When a discussion turned to nursing's seemingly extraordinary emphasis on documentation, she explained that nursing students did not always have solid a grammar school education; the emphasis on documentation was to improve writing skills. I hadn't thought of that conversation until now, nor considered the influence of public education in the early half of the 20th century on the development of the nursing profession. Students from farm families may have missed school to help with planting and harvesting, and students from urban families may not have completed high school for having to work to help support their families. Nursing students with fathers who held "higher" level occupations were more likely to have a different educational experience than those with "lower" occupations. Today we think in terms of equity and inclusion, but this early data was capturing the same notion that not all individuals have equal access or pathways to nursing careers. And why is it that the researchers decided nursing did not appeal to minorities while recognizing limited efforts to reach out to minority groups? Our progress in diversifying the workforce has been too slow.
As we rebuild the nursing workforce in this post-pandemic era, the questions asked by the ANA research program capture the broad areas we need to now reconsider. It's time for deepening our understanding of nursing practice, satisfiers and dissatisfiers, interprofessional team relationships, educational requirements, and the wellbeing of the nurse as a person.
The list of functions in Table 1 should feel oddly familiar. These 1950 functions of a nurse have served as the bedrock on which today's nursing practice is built. Line them up next to today's scope of practice statements and see the deep roots. Most notably, the functions are not statements of tasks but rather statements reflecting professional judgement grounded in education and experience and leading to improved health outcomes. Ah, yes! Nurse work is think work, judgment work, and we have known it all along!
The nurses' quotes scattered throughout the book provide testimony to the consistency of caring as core to nursing practice and the dedication of nurses to the work of nursing. Nursing is physically challenging yet hard to quit even when advancing age demands. Overall, things have improved. Our salaries are better, we no longer leave nursing careers to become a June Cleaver housewife after marriage and children, and we no longer stand when a physician enters the room.
To know your history is to know your power. Nursing history is rarely emphasized in today's curricula if taught at all, and we are the worst off for it. We stand on the shoulders of those ANA leaders who provided the vision for research that launched the outlines of our contemporary nursing practice. And we must acknowledge the ANA members who funded the program "out of their pockets." I don't know how this book found its way to my bookshelf, but I'm ever so grateful it did.
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